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Incident Report Form

“Incident” is an unforeseen or unexpected occurrence that could lead to bodily harm or injury and/or damage to property are without apparent or deliberate cause and can happen to anyone involved – volunteers, clients, staff and/or community members and this can include breaking boundaries or rules, failing to follow instructions, near-accidents or any occurrence that is problematic.

Or a circumstance serious enough to require immediate attention to a volunteer, client or staff it can occur because of a volunteer’s actions, or instead in the presence of a volunteer.

All parties present during an incident – volunteers and/or staff – are required to fill out an incident report form. Use the following format:

Date of Incident:

Time of Incident:

Location of Incident:

Specific Location of Incident or if 'Other' Specify Where:

Report Completed By:

Staff or Volunteer ID Number:

Names of Individual(s) Involved:

Nature of Incident: (select multiple if aplicable)

Details of the Incident:

Circumstances Leading to the Incident:

Was there a Supervisor Present:

Name of Supervisor Present:

Action Taken (by you or another individual):

Who was contacted?